Our understanding of ALDLT has advanced significantly since the initial establishment of the A2ALL consortium; however, several important research issues and clinical questions regarding ALDLT remain unanswered. These include fundamental questions regarding the impact of this procedure on the long-term health and well-being of living donors, especially beyond the 1st year postdonation. With regards to recipient outcomes, the technical surgical problems associated with the procedure remain of paramount importance and the surgical limitations of this procedure, as well as methods to overcome these problems, are poorly defined. Our overall goals are to study the short- and long-term effects of ALDLT on the donor and recipient and to gain insight into unique donor and recipient issues through study of this innovative procedure, which will be achieved by full participation in the A2ALL consortium in collaboration with other transplant centers and the data coordinating center. With regards to long- term donor follow up, our aim is to advance beyond generic measures of QOL already included in A2ALL and determine (a) the prevalence and temporal patterns of psychiatric symptomatology and diagnosable mood and anxiety disorders in the extended years following donation; (b) the level of enduring fatigue, other somatic symptoms, and lasting health concerns in the extended years post-donation; and (c) identify the long term financial consequences for donors including health-related financial expenses, changes in employment, and changes in health, disability, or life insurance benefits. Finally, with regards to specific technical issues related to the recipient surgery, our aim is to study the specific risk factors involved in the development of small-for-size-syndrome (SFSS) in recipients after ALDLT - most specifically the impact of portal pressure measurements and inflow modification on the risk for SFSS. Our hypothesisis is that SFSS likely represents a portal hyperperfusion injury to the hepatic sinusoids and measurements of portal pressures and portal flow likely represents the best predictor for SFSS. A randomized study is proposed to look at the impact of inflow modification (specifically splenic artery ligation) vs. no intervention on liver regeneration and risk for developing SFSS in recipients identified to have elevated portal pressure post reperfusion of the liver graft. PUBLIC HEALTH RELEVANCE: A collaborative effort such as the A2ALL will be the only way to advance the field of adult living donor liver transplant in this country as there are no single centers doing enough volume of this procedure to perform any meaningful analysis. The findings from this effort will help to better define the role of this procedure in this country today, the risks (especially long term for the donor) associated with donation, and methods that can perhaps improve the success rates seen with this procedure.